PRACTICAL REMARKS ON DROPSY, AND SOME OTHER DISEASES.

The following remarks consist partly of matter of fact, and partly of opinion. The former will be permanent; the latter must vary with the detection of error, or the improvement of knowledge. I hazard them with diffidence, and hope they will be examined with candour; not by a contrast with other opinions, but by an attentive comparison with the phœnomena of disease.

ANASARCA.

§ 1. The anasarca is generally curable when seated in the sub-cutaneous cellular membrane, or in the substance of the lungs.

§ 2. When the abdominal viscera in general are greatly enlarged, which they sometimes are, without effused fluid in the cavity of the abdomen; the disease is incurable. After death, the more solid viscera are found very large and pale. If the cavity contains water, that water may be removed by diuretics.

§ 3. In swollen legs and thighs, where the resistance to pressure is considerable, the tendency to transparency in the skin not obvious, and where the alteration of posture occasions but little alteration in the state of distension, the cure cannot be effected by diuretics.

Is this difficulty of cure occasioned by spissitude in the effused fluids, by want of proper communication from cell to cell, or is the disease rather caused by a morbid growth of the solids, than by an accumulation of fluid?

Is not this disease in the limbs similar to that of the viscera (§ 2)?

§ 4. Anasarcous swellings often take place in palsied limbs, in arms as well as legs; so that the swelling does not depend merely upon position.

§ 5. Is there not cause to suspect that many dropsies originate from paralytic affections of the lymphatic absorbents? And if so, is it not probable that the Digitalis, which is so effectual in removing dropsy, may also be used advantageously in some kinds of palsy?

ASCITES.

§ 6. If existing alone, (i. e.) without accompanying anasarca, is in children curable; in adults generally incurable by medicines. Tapping may be used here with better chance for success than in more complicated dropsies. Sometimes cured by vomiting.

ASCITES and ANASARCA.

§ 7. Incurable if dependant upon irremediably diseased viscera, or on a gouty constitution, so debilitated, that the gouty paroxysms no longer continue to be formed.

In every other situation the disease yields to diuretics and tonics.

ASCITES, ANASARCA, and HYDROTHORAX.

§ 8. Under this complication, though the symptoms admit of relief, the restoration of the constitution can hardly be hoped for.

ASTHMA.

§ 9. The true spasmodic asthma, a rare disease—is not relieved by Digitalis.

§ 10. In the greater part of what are called asthmatical cases, the real disease is anasarca of the lungs, and is generally to be cured by diuretics. (See § 1.) This is almost always combined with some swelling of the legs.

§ 11. There is another kind of asthma, in which change of posture does not much affect the patient. I believe it to be caused by an infarction of the lungs. It is incurable by diuretics; but it is often accompanied with a degree of anasarca, and so far it admits of relief.

Is not this disease similar to that in the limbs at (§ 3,) and also to that of the abdominal viscera at (§ 2.)?

ASTHMA and ANASARCA.

§ 12. If the asthma be of the kind mentioned at (§§ 9 and 11,) diuretics can only remove the accompanying anasarca. But if the affection of the breath depends also upon cellular effusion, as it mostly does, the patient may be taught to expect a recovery.

ASTHMA and ASCITES.

§ 13. A rare combination, but not incurable if the abdominal viscera are sound. The asthma is here most probably of the anasarcous kind (§ 10;) and this being seldom confined to the lungs only, the disease generally appears in the following form.

ASTHMA, ASCITES, and ANASARCA.

§ 14. The curability of this combination will depend upon the circumstances mentioned in the preceding section, taking also into the account the strength or weakness of the patient.

EPILEPSY.

§ 15. In epilepsy dependant upon effusion, the Digitalis will effect a cure; and in the cases alluded to, the dropsical symptoms were unequivocal. It has not had a sufficient trial in my hands, to determine what it can do in other kinds of epilepsy.

HYDATID DROPSY.

§ 16. This may be distinguished from common ascites, by the want of evident fluctuation. It is common to both sexes. It does not admit of a cure either by tapping or by medicine.

HYDROCEPHALUS.

§ 17. This disease, which has of late so much attracted the attention of the medical world, I believe, originates in inflammation; and that the water found in the ventricles of the brain after death, is the consequence, and not the cause of the illness.

It has seldom happened to me to be called upon in the earlier stages of this complaint, and the symptoms are at first so similar to those usually attendant upon dentition and worms, that it is very difficult to pronounce decidedly upon the real nature of the disease; and it is rather from the failure of the usual modes of relief, than from any other more decided observation, that we at length dare to give it a name.

At first, the febrile symptoms are sometimes so unsteady, that I have known them mistaken for the symptoms of an intermittent, and the cure attempted by the bark.

In the more advanced stages, the diagnostics obtrude themselves upon our notice, and put the situation of the patient beyond a doubt. But this does not always happen. The variations of the pulse, so accurately described by the late Dr. Whytt, do not always ensue. The dilatation of the pupils, the squinting, and the aversion to light, do not universally exist. The screaming upon raising the head from the pillow or the lap, and the flushing of the cheeks, I once considered as affording indubitable marks of the disease; but in a child which I sometime since attended with Dr. Ash, the pulse was uniformly about 85, (except during the first week, before we had the care of the patient.) The child never shewed any aversion to the light; never had dilated pupils, never squinted, never screamed when raised from the lap or taken out of the bed, nor did we observe any remarkable flushing of the cheeks; and the sleep was quiet, but sometimes moaning.

Frequent vomiting existed from the first, but ceased for several days towards the conclusion. One or two worms came away during the illness, and it was all along difficult to purge the child. Three days before death, the right side became slightly paralytic, and the pupil of that eye somewhat dilated.

After death, about two ounces and a half of water were found in the ventricles of the brain, and the vessels of the dura mater were turgid with blood.

If I am right as to the nature of hydrocephalus, that it is at first dependant upon inflammation, or congestion; and that the water in the ventricles is a consequence, and not a cause of the disease; the curative intentions ought to be extremely different in the first and the last stages.

It happens very rarely that I am called to patients at the beginning, but in two instances wherein I was called at first, the patients were cured by repeated topical bleedings, vomits, and purges.

Some years ago I mentioned these opinions, and the success of the practice resulting from them, to Dr. Quin, now physician at Dublin. That gentleman had lately taken his degree, and had chosen hydrocephalus for the subject of his thesis in the year 1779. In this very ingenious essay, which he gave me the same morning, I was much pleased to find that the author had not only held the same ideas relative to the nature of the disease, but had also confirmed them by dissections.

In the year 1781, another case in the first stage demanded my attention. The reader is referred back to Case LXIX for the particulars.

I have not yet been able to determine whether the Digitalis can or cannot be used with advantage in the second stage of the hydrocephalus. In Case XXXIII. the symptoms of death were at hand; in Case LXIX. the practice, though successful, was too complicated, and in Case CLI. the medicine was certainly stopped too soon.

When we consider what enormous quantities of mercury may be used in this complaint, without affecting the salivary glands, it seems probable that other parts may be equally insensible to the action of their peculiar stimuli, and therefore that the Digitalis ought to be given in much larger doses in this, than in other diseases.

HYDROTHORAX.

§ 18. Under this name I also include the dropsy of the pericardium.

The intermitting pulse, and pain in the arms, sufficiently distinguish this disease from asthma, and from anasarcous lungs.

It is very universally cured by the Digitalis.

§ 19. I lately met with two cases which had been considered and treated as angina pectoris. They both appeared to me to be cases of hydrothorax. One subject was a clergyman, whose strength had been so compleatly exhausted by the continuance of the disease, and the attempts to relieve it, that he did not survive many days. The other was a lady, whose time of life made me suspect effusion. I directed her to take small doses of the pulv. Digitalis, which in eight days removed all her complaints. This happened six months ago, and she remains perfectly well.

HYDROTHORAX and ANASARCA.

§ 20. This combination is very frequent, and, I believe, may always be cured by the Digitalis.

§ 21. Dropsies in the chest either with or without anasarcous limbs, are much more curable than those of the belly. Probably because the abdominal viscera are more frequently diseased in the latter than in the former cases.

INSANITY.

§ 22. I apprehend this disease to be more frequently connected with serous effusion than has been commonly imagined.

§ 23. Where appearances of anasarca point out the true cause of the complaint, as in cases XXIV. and XXXIV. the happiest effects may be expected from the Digitalis; and men of more experience than myself in cases of insanity, will probably employ it successfully in other less obvious circumstances.

NEPHRITIS CALCULOSA.

§ 24. We have had sufficient evidence of the efficacy of the Foxglove in removing the Dysuria and other symptoms of this disease; but probably it is not in these cases preferable to the tobacco.[12]

OVARIUM DROPSY.

§ 25. This species of encysted dropsy is not without difficulty distinguishable from an ascites; and yet it is necessary to distinguish them, because the two diseases require different treatment and because the probality of a cure is much greater in one than in the other.

§ 26. The ovarium dropsy is generally slow in its progress; for a considerable time the patient though somewhat emaciated, does not lose the appearance of health, and the urine flows in the usual quantity. It is seldom that the practitioner is called in early enough to distinguish by the feel on which side the cyst originated, and the patients do not attend to that circumstance themselves. They generally menstruate regularly in the incipient state of the disease, and it is not until the pressure from the sac becomes very great, that the urinary secretion diminishes. In this species of dropsy, the patients, upon being questioned, acknowledge even from a pretty early date, pains in the upper and inner parts of the thighs, similar to those which women experience in a state of pregnancy. These pains are for a length of time greater in one thigh than in the other, and I believe it will be found that the disease originated on that side.

§ 27. The ovarium dropsy defies the power of medicine. It admits of relief, and sometimes of a cure, by tapping. I submit to the consideration of practitioners, how far we may hope to cure this disease by a seton or a caustic.—In the LXIst case the patient was too much reduced, and the disease too far advanced to allow of a cure by any method; but it teaches us that a caustic may be used with safety.

§ 28. When tapping becomes necessary, I always advise the adoption of the waistcoat bandage or belt, invented by the late very justly celebrated Dr. Monro, and described in the first volume of the Medical Essays. I also enjoin my patients to wear this bandage afterwards, from a persuasion that it retards the return of the disease. The proper use of bandage, when the disorder first discovers itself, certainly contributes much to prevent its increase.

OVARIUM DROPSY with ANASARCA.

§ 29. The anasarca does not appear until the encysted dropsy is very far advanced. It is then probably caused by weakness and pressure. The Digitalis removes it for a time.

PHTHISIS PULMONALIS.

§ 30. This is a very increasing malady in the present day. It is no longer limited to the middle part of life: children at five years of age die of it, and old people at sixty or seventy. It is not confined to the flat-chested, the fair-skinned, the blue eyed, the light-haired, or the scrophulous: it often attacks people with full chests, brown skins, dark hair and eyes, and those in whose family no scrophulous taint can be traced. It is certainly infectious. The very strict laws still existing in Italy to prevent the infection from consumptive patients, were probably not enacted originally without a sufficient cause. We seem to be approaching to that state which first made such restrictions necessary, and in the further course of time, the disease will probably fall off again, both in virulency and frequency.

§ 31. The younger part of the female sex are liable to a disease very much resembling a true consumption, and from which it is difficult to distinguish it; but this disease is curable by steel and bitters. A criterion of true phthisis has been sought for in the state of the teeth; but the exceptions to that rule are numerous. An unusual dilatation of the pupil of the eye, is the most certain characteristic.[13]

§ 32. Sydenham asserts, that the bark did not more certainly cure an intermittent, than riding did a consumption. We must not deny the truth of an assertion, from such authority, but we must conclude that the disease was more easily curable a century ago than it is at present.

§ 33. If the Digitalis is no longer useful in consumptive cases, it must be that I know not how to manage it, or that the disease is more fatal than formerly; for it would be hard to deny the testimony cited at page 9. I wish others would undertake the enquiry.

§ 34. When phthisis is accompanied with anasarca, or when there is reason to suspect hydrothorax, the Digitalis will often relieve the sufferings, and prolong the life of the patient.

§ 35. Many years ago, during an attendance upon Mr. B——, of a consumptive family, and himself in the last stage of a phthisis; after he was so ill as to be confined to his chamber, his breathing became so extremely difficult and distressing, that he wished rather to die than to live, and urged me warmly to devise some mode to relieve him. Suspecting serous effusion to be the cause of this symptom, and he being a man of sense and resolution, I fully explained my ideas to him, and told him what kind of operation might afford him a chance of relief; for I was then but little acquainted with the Digitalis. He was earnest for the operation to be tried, and with the assistance of Mr. Parrott, a very respectable surgeon of this place, I got an opening made between the ribs upon the lower and hinder part of the thorax. About a pint of fluid was immediately discharged, and his breath became easy. This fluid coagulated by heat.

After some days a copious purulent discharge issued from the opening, his cough became less troublesome, his expectoration less copious, his appetite and strength returned, he got abroad, and the wound, which became very troublesome, was allowed to heal.

He then undertook a journey to London; whilst there he became worse: returned home, and died consumptive some weeks afterwards.

PUERPERAL ANASARCA.

§ 36. This disease admits of an easy and certain cure by the Digitalis.

§ 37. This species of dropsy may originate from other causes than child birth. In the beginning of last March, a gentleman at Wolverhampton desired my advice for very large and painful swelled legs and thighs. He was a temperate man, not of a dropsical habit, had great pain in his groins, and attributed his complaints to a fall from his horse. He had taken diuretics, and the strongest drastic purgatives with very little benefit. Considering the anasarca as caused by the diseased inguinal glands, I ordered common poultice and mercurial ointment to the groins, three grains of pulv. fol. Digitalis night and morning, and a cooling diuretic decoction in the day-time. He soon lost his pain, and the swellings gradually subsided.

THE END.

FOOTNOTES:

BOOKS, Printed for G. G. J. and J. ROBINSON, Booksellers, Paternoster-Row, London.

AN ACCOUNT OF THE Scarlet Fever and Sore Throat, Or, SCARLATINA ANGINOSA; Particularly as it appeared at BIRMINGHAM in the Year 1778.

By WILLIAM WITHERING, M. D.

Price 1s. 6d.

Also, Price 2s. 6d.

Outlines of MINERALOGY, Translated from the original of Sir Torbern Bergman; with NOTES,

By WILLIAM WITHERING, M. D.

Member of the Royal Medical Society at Edinburgh.

In the Spring of the Year 1786, will be published, by the same Author, a New Edition of the BOTANICAL ARRANGEMENT. With very great Additions; in Three Vols. large Octavo.

Transcriber's Notes

Obvious printer's errors have been fixed. For the detailed list, please see below. The frontispiece has been moved from the beginning of the book to the section explaining it.

Errors fixed

page xvi—typo fixed: changed 'afterterwards' to 'afterwards'

page 029—typo fixed: changed 'apetite' to 'appetite'

page 043—typo fixed: removed an extra 'in' after 'and she died'

page 062—typo fixed: changed 'Dovers' to 'Dover's' after 'seneka'

page 095—typo fixed: changed 'ef' to 'of' after 'whilst the rest'

page 098—typo fixed: changed 'harrassed' to 'harassed'

page 103—typo fixed: changed 'Shiffnal' to 'Shiffnall'

page 106—spelling normalized: changed 'Fox-glove' to 'Foxglove'

page 110—typo fixed: changed 'suceed' to 'succeed' after 'hope it might'

page 111—typo fixed: changed 'atttention' to 'attention' after 'repeated without'

page 114—typo fixed: changed 'disgreeable' to 'disagreeable' after 'or any other'

page 115—typo fixed: removed an extra 'the' in front of '7th of April'

page 123—typo fixed: changed 'susspended' to 'suspended' after 'the medicine to be'

page 135—typo fixed: changed 'vomitted' to 'vomited' after 'that she'

page 141—typo fixed: changed 'contiued' to 'continued' after 'He'

page 148—typo fixed: changed 'praecordia' to 'prœcordia'

page 158—typo fixed: changed 'spoonfulls' to 'spoonfuls'

page 163—typo fixed: changed 'mecine' to 'medicine'

page 164—typo fixed: changed 'slighest' to 'slightest' after 'distressing on the'

page 166—typo fixed: changed 'ipecacohana' to 'ipecacoanha'

page 170—typo fixed: changed 'meridiaana' to 'meridiana'

page 196—typo fixed: removed an extra 'the' in front of 'abdominal viscera'

page 200—typo fixed: removed an extra 'and' after 'from asthma'